Pickup Laura, Atkinson Sarah, Hollnagel Erik, Bowie Paul, Gray Sandra, Rawlinson Sam, Forrester Kate
Human Factors Department, The University of Nottingham, ITRC Building, Nottingham, NG7 2RD, United Kingdom.
Center for Quality Improvement, Southern Region, Denmark.
Appl Ergon. 2017 Mar;59(Pt A):234-242. doi: 10.1016/j.apergo.2016.08.027. Epub 2016 Sep 14.
This study aimed to investigate why there is variability in taking blood. A multi method Pilot study was completed in four National Health Service Scotland hospitals. Human Factors/Ergonomics principles were applied to analyse data from 50 observations, 15 interviews and 12-months of incident data from all Scottish hospitals. The Functional Resonance Analysis Method (FRAM) was used to understand why variability may influence blood sampling functions. The analysis of the 61 pre blood transfusion sampling incidents highlighted limitations in the data collected to understand factors influencing performance. FRAM highlighted how variability in the sequence of blood sampling functions and the number of practitioners involved in a single blood sampling activity was influenced by the working environment, equipment, clinical context, work demands and staff resources. This pilot study proposes a realistic view of why blood sampling activities vary and proposes the need to consider the system's resilience in future safety management strategies.
本研究旨在调查采血过程中存在变异性的原因。在苏格兰国民保健服务体系的四家医院开展了一项多方法试点研究。应用人因学/工效学原理分析了50次观察、15次访谈的数据以及来自所有苏格兰医院的12个月事件数据。功能共振分析方法(FRAM)被用于理解变异性为何可能影响采血功能。对61起输血前采样事件的分析突出了所收集数据在理解影响操作表现因素方面的局限性。FRAM突出了采血功能顺序的变异性以及单次采血活动中涉及的从业者数量是如何受到工作环境、设备、临床背景、工作需求和人员资源的影响。这项试点研究对采血活动为何存在差异提出了现实的观点,并提出在未来安全管理策略中需要考虑系统的恢复力。